The long-term objective of this research is to improve the quality of care and health outcomes of indigent, vulnerable patients with diabetes who receive their care at rural and urban community health centers (CHC), critical sites of primary care for 10 million Americans who reside in medically underserved areas. The research should also inform efforts to manage other chronic diseases in these settings, and it is important in its own right since diabetes affects 10 million patients, costs 100 billion dollars annually, and causes significant complications including retinopathy, nephropathy, neuropathy, and cardiovascular disease. Investigators will test 2 models of quality improvement applied to diabetes care in CHCs: (1) a collaborative approach incorporating intensive, extended training in total quality management and a chronic disease model, group brainstorming and problem-solving, and development of skills in provider-patient communication; and (2) a control model consisting of basic, brief training in total quality management and a chronic disease model. They hypothesize that the intensive collaborative approach will prove more effective in improving diabetes care. By the end of project year 1, 40 CHCs in the MidWest Clinicians' Network (MWCN), a not-for-profit organization of 70 CHCs serving indigent vulnerable patients in 10 Midwestern states, will receive basic training in total quality management and a chronic disease model. At the end of year 1, the 40 CHCs will be randomized either to the intensive intervention or usual care. All CHCs will also receive feedback of data. Investigators will use hierarchical regression models to compare the 2 quality improvement approaches across several process and outcome measures such as rates of referral for dilated ophthalmological examination and values of glycosylated hemoglobin. They will also perform case studies of the CHCs to describe the barriers and facilitators of implementing the collaborative intervention, as well as the individual interventions made at each CHC. This proposal builds on an established research relationship among the principal investigator, Marshall Chin, MD, MPH, the University of Chicago, and MWCN. While the interventions are designed to succeed in the particularly challenging CHC setting, the findings should be generalizable to health systems with more resources and to other chronic diseases.